Clone of Midwest Small Breed Rescue

Date

Name

E-mail

Age

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Alternative Phone Number

Area CodePhone Number

Alternative Phone Number

Employer

Why are you interested in fostering a dog?

On a scale of 1 (low energy) to 5 (high energy)...what activity level are you looking for?

Do you currently own any pets?

If yes, please list BREED/AGE/SEX:

Are your current animals up to date on all shots?

Are your current animals spayed/neutered?

If not, explain the reason that they are not spayed/neutered:

Have you ever given a pet away?

If yes, explain your reason:

Current/Past Veterinarian: If none, type "none."

Phone Number of Veterinarian

Area CodePhone Number

Name account is under

Approximate date/reason of last Veterinarian visit:

Do you live in a:

Social Environment

Do you own or rent?

How long have you lived at this address?

If you rent, do you have your landlord's permission to have a pet?

If you rent, provide name of Landlord: (We will contact your landlord to verify that your lease allows for pet ownership.)

Landlord's Phone Number

Area CodePhone Number

Do you have a fenced yard?

What is type and height of fence?

If no fence, how do you plan on taking the dog outside to exercise and potty?

How many adults in your household? What is relationship to applicant?

How many children in your household? (List ages)

Do you have young children visit your home on a regular basis (i.e., grandchildren, babysitting, etc.)

Is everyone in your home agreeable to fostering a rescue dog

Where will dog spend most of his/her time? Give details.

How many hours will dog be home alone during the day?

Where will dog stay when home alone? Give details.

Do you understand that even though a dog may be housebroken, when they move to a new environment there is an adjustment period where they may have accidents in their new home? Housebreaking techniques will need to be utilized.

What type of potty training methods will you use? (Give details)

Will you be willing to work with us to correct any possible behavior problems that develop after adoption?

Are you physically able to care for a dog? If limitations, please explain.

I grant Midwest Small Breed Rescue permission to conduct a home check.

Do you have any additional information you would like to provide?

I understand by submitting this application, I am declaring that the information I have provided in this application is complete and correct.

Midwest Small Breed Rescue Foster Application